HIGHLY CONFIDENTIAL AND PRIVILEGED 1 CLIENT DATA SHEET: DURABLE POWER OF ATTORNEY FOR PROPERTY Return to: Rincker Law, PLLC c/o Cari Rincker, Esq. 11 Broadway, Suite 615 New York, NY 10004 (office) (212) 427-2049 (fax) (212) 202-6077 cari@rinckerlaw.com www.rinckerlaw.com NOTICE: This document is highly confidential and protected by attorney-client privilege. It contains sensitive financial information and personal identification numbers. If you have come across this document in error, you are hereby notified that you must not read, save, record, print, forward, distribute, publish, or use the information contained in this document and any dissemination is strictly prohibited. Please contact Rincker Law, PLLC immediately for further instructions. HIGHLY CONFIDENTIAL AND PRIVILEGED 2 I. CLIENT’S INFORMATION (“PRINCIPAL”) A. Principal _____________________________ ______________________________ Full Legal Name Formally Known As/Also Known As __________________________________________________________________ Address _______________________________ _______________ ____________ City State Zip _______________________________ ______________________________ Phone Number Email _______________________________ ______________________________ Date of Birth Social Security Number B. Spouse _____________________________ ______________________________ Full Legal Name Formally Known As/Also Known As __________________________________________________________________ Address _______________________________ _______________ ____________ City State Zip _______________________________ ______________________________ Phone Number Email _______________________________ ______________________________ Date of Birth Social Security Number HIGHLY CONFIDENTIAL AND PRIVILEGED 3 C. Children 1. Child _____________________________ ______________________________ Full Legal Name Formally Known As/Also Known As __________________________________________________________________ Address _______________________________ _______________ ____________ City State Zip _______________________________ ______________________________ Phone Number Email _______________________________ ______________________________ Date of Birth Social Security Number Check: ☐Male ☐Female 2. Child _____________________________ ______________________________ Full Legal Name Formally Known As/Also Known As __________________________________________________________________ Address _______________________________ _______________ ____________ City State Zip _______________________________ ______________________________ Phone Number Email _______________________________ ______________________________ Date of Birth Social Security Number Check: ☐Male ☐Female HIGHLY CONFIDENTIAL AND PRIVILEGED 4 3. Child _____________________________ ______________________________ Full Legal Name Formally Known As/Also Known As __________________________________________________________________ Address _______________________________ _______________ ____________ City State Zip _______________________________ ______________________________ Phone Number Email _______________________________ ______________________________ Date of Birth Social Security Number Check: ☐Male ☐Female II. INFORMATION ON PROPOSED AGENTS A. PROPOSED AGENT(S) _____________________________ ______________________________ Full Legal Name Formally Known As/Also Known As __________________________________________________________________ Address _______________________________ _______________ ____________ City State Zip _______________________________ ______________________________ Phone Number Email _______________________________ ______________________________ Date of Birth Social Security Number ________________________________ Check: ☐Male ☐Female Relationship to Principal HIGHLY CONFIDENTIAL AND PRIVILEGED 5 _____________________________ ______________________________ Full Legal Name Formally Known As/Also Known As __________________________________________________________________ Address _______________________________ _______________ ____________ City State Zip _______________________________ ______________________________ Phone Number Email _______________________________ ______________________________ Date of Birth Social Security Number ________________________________ Check: ☐Male ☐Female Relationship to Principal Do you wish for these two people to act jointly or separately as agents? _______________________________________________________________________ B. PROPOSED SUCCESSOR AGENT(S) _____________________________ ______________________________ Full Legal Name Formally Known As/Also Known As __________________________________________________________________ Address _______________________________ _______________ ____________ City State Zip _______________________________ ______________________________ Phone Number Email _______________________________ ______________________________ Date of Birth Social Security Number ________________________________ Check: ☐Male ☐Female Relationship to Principal HIGHLY CONFIDENTIAL AND PRIVILEGED 6 _____________________________ ______________________________ Full Legal Name Formally Known As/Also Known As __________________________________________________________________ Address _______________________________ _______________ ____________ City State Zip _______________________________ ______________________________ Phone Number Email _______________________________ ______________________________ Date of Birth Social Security Number ________________________________ Check: ☐Male ☐Female Relationship to Principal Do you wish for these two people to act jointly or separately as Successor Agents? _______________________________________________________________________ C. PROPOSED ALTERNATIVE SUCCESSOR AGENTS _____________________________ ______________________________ Full Legal Name Formally Known As/Also Known As __________________________________________________________________ Address _______________________________ _______________ ____________ City State Zip _______________________________ ______________________________ Phone Number Email _______________________________ ______________________________ Date of Birth Social Security Number ________________________________ Check: ☐Male ☐Female Relationship to Principal _____________________________ ______________________________ Full Legal Name Formally Known As/Also Known As HIGHLY CONFIDENTIAL AND PRIVILEGED 7 __________________________________________________________________ Address _______________________________ _______________ ____________ City State Zip _______________________________ ______________________________ Phone Number Email _______________________________ ______________________________ Date of Birth Social Security Number ________________________________ Check: ☐Male ☐Female Relationship to Principal Do you wish for these two people to act jointly or separately as Alternative Successor Agents? _______________________________________________________________________ III. INFORMATION FOR POWERS OF ATTORNEY A. When do you wish for this Power of Attorney to take effect? Check: ☐Immediately ☐If my attending physician and/or court says that I have lost mental capacity B. What kind of powers do you wish to give your agent(s)? Check all that apply: ☐real estate transactions ☐financial institutions ☐stock and bond transactions ☐personal property transactions ☐safe deposit box transactions ☐ insurance/annuity transactions ☐retirement plan transactions ☐social security, employment and/or military benefits ☐ tax matters ☐claims and litigation ☐commodity and option transactions ☐business operations ☐borrowing transactions HIGHLY CONFIDENTIAL AND PRIVILEGED 8 ☐estate transactions ☐all other property powers C. Are there any limitations that you would like on your Agent? (e.g., prohibitions on specific assets or special rules on borrowing) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ D. Would you like to give your Agent any additional powers of authority? (e.g., power to make gifts, powers of appointment, name/change beneficiaries or joint tenants, revoke/amend trusts) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ E. Would you like for your Agent to have the ability to delegate his/her authority to other persons? Check: ☐Yes ☐No F. Would you like for your Agent to have the right to receive reasonable compensation for services rendered under the Power of Attorney? Check: ☐Yes ☐No G. Choice of Law Check: ☐New York ☐New Jersey ☐Connecticut ☐Other: _____________________ H. Besides the office Rincker Law, PLLC, where will original and copies of the Power of Attorney be kept? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ I. Other: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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